Violation Details: 00327565-AP-278940

Date
4/26/2024
Report number
00327565-AP-278940
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to properly plan care
Result
Substantiated
Findings
The Alleged Victim (AV) relies on the facility for his/her care. The Alleged Victim (AV) is a known fall risk with a history of falls. According to AV’s care plan, AV had very poor vision and was unable to see about a foot in front of him/her, but was care planned as independent in ambulation, transfers, and the use of the call button system. AV was known to not use his/her walker in his/her apartment and would ambulate very quickly. Between April 16,2024 and April 18, 2024, AV experienced three falls, resulting in skin tears and repeated unreasonable discomfort. The facility failed to implement interventions or appropriately care plan, to mitigate the risk of injury due to AV's increase in falls, which is a violation of resident rights, is neglect of care which constitutes abuse.
Sanction
ALFCP25-00033 $1125.00 fine assessed